Chapter 11 - Nurse note documentation, level 3. After completing Chapter 11, the students will be able to: Carry out documentation of patient education and response, identify patient response to interventions, carry out documentation re-assessment/revision of goals, use Todo/Reminders within the Nurse Note. | Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 11 Content LO Teaching (Patient Education) LO Evaluation LO Reassessment LO F/U-REM (Follow-up Reminders/ToDo List) LO TEACHING (PATIENT EDUCATION) LO Teaching (Patient Education) Patient education Key intervention for nursing SpringCharts has specific area focused on documentation of instruction Intervention component of SOAPIER LO EVALUATION LO Evaluation Evaluation Patient progress toward meeting outcomes must be evaluated routinely Determine if nursing interventions are effective Determine if outcomes have been met or if the plan of care requires revision LO REASSESSMENT LO Reassessment Reassessment Response to intervention Analgesic Diuretics Post-procedure Surgery Heart catheterization LO F/U-REM (FOLLOW-UP REMINDERS/TODO LIST) LO F/U-REM (Follow-up Reminders/ToDo List) Follow-up reminders . | Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 11 Content LO Teaching (Patient Education) LO Evaluation LO Reassessment LO F/U-REM (Follow-up Reminders/ToDo List) LO TEACHING (PATIENT EDUCATION) LO Teaching (Patient Education) Patient education Key intervention for nursing SpringCharts has specific area focused on documentation of instruction Intervention component of SOAPIER LO EVALUATION LO Evaluation Evaluation Patient progress toward meeting outcomes must be evaluated routinely Determine if nursing interventions are effective Determine if outcomes have been met or if the plan of care requires revision LO REASSESSMENT LO Reassessment Reassessment Response to intervention Analgesic Diuretics Post-procedure Surgery Heart catheterization LO F/U-REM (FOLLOW-UP REMINDERS/TODO LIST) LO F/U-REM (Follow-up Reminders/ToDo List) Follow-up reminders Allows nurse to set reminders for follow-up care Useful for discharge . | Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 11 Content LO Teaching (Patient Education) LO Evaluation LO Reassessment LO F/U-REM (Follow-up Reminders/ToDo List) LO TEACHING (PATIENT EDUCATION) LO Teaching (Patient Education) Patient education Key intervention for nursing SpringCharts has specific area focused on documentation of instruction Intervention component of SOAPIER LO EVALUATION LO Evaluation Evaluation Patient progress toward meeting outcomes must be evaluated routinely Determine if nursing interventions are effective Determine if outcomes have been met or if the plan of care requires revision LO REASSESSMENT LO Reassessment Reassessment Response to intervention Analgesic Diuretics Post-procedure Surgery Heart catheterization LO F/U-REM (FOLLOW-UP REMINDERS/TODO LIST) LO F/U-REM (Follow-up Reminders/ToDo List) Follow-up reminders Allows nurse to set reminders for follow-up care Useful for discharge disposition
